The Massachusetts plan for universal coverage – recently signed into law – signals a new urgency in addressing the growing crisis in the U.S. health care system and highlights the policy vacuum on this issue in our nation’s capital. I applaud the Massachusetts governor and legislature for their courage and innovation; yet the plan itself is based on a false assumption. Like the Oregon Health Plan – enacted when I was senate president and implemented while I was governor – it treats only a symptom of the problem, not the problem itself.
Certainly ensuring everyone has timely access to needed medical care must be a key objective of any serious reform effort – and expanding coverage was a central component of our efforts in Oregon. But I have come to believe that universal coverage by itself will not solve our health care crisis. For example, everyone over the age of 65 is already covered by the Medicare program, yet the result of this universal coverage is an unfunded entitlement in excess of $65 trillion that casts a dark shadow over our nation’s fiscal future.
The uninsured are the symptom of a much deeper problem. The problem is our federal eligibility and financing structure for health care. This structure reflects the realities of the mid-20th century, not the realities of today, resulting in an increasingly inequitable and unsustainable set of public subsidies. The problem is embedded in the way we define a health care “benefit” and in the payment models and financial incentives through which this health care is delivered.
Achieving universal coverage without examining what is covered and how services are delivered will do little to stem escalating medical costs, make health care more affordable or mitigate the growing disadvantage faced by U.S. businesses competing in a global economy against firms not burdened by the spiraling cost of providing health care to their employees.
Other proposals for expanding coverage are cropping up in Indiana, Maine, Oregon and a number of other states. I recently spoke to the American College of Physicians which also has a plan for universal coverage. I encourage all these efforts, but I am concerned that this narrow focus on coverage is distracting us from the larger and more central issue: the 50 year old assumptions on which the huge public subsidies in our current system are built. Clinging to these assumptions and expecting to resolve the growing crisis in our health care system is like Bill Gates clinging to a 50 year old operating system and expecting Microsoft to be competitive in the 21st century.
Trying to figure out the cost of universal coverage without knowing what we are covering or the nature of the system through which these “benefits” will be delivered is like trying to determine the cost of a banquet armed only with a guest list – but without a menu or knowing how and by whom the food will be prepared and served.
We must not lose sight of our fundamental objective here – which is health, not just the financing and delivery of health care. As a physician I have had considerable firsthand knowledge that health care is not always synonymous with health. It is but a means to an end – not an end in itself – and has no intrinsic value outside of its relationship to health, except as an economic commodity.
We do need universal access but what we need access to is not the current system. We need access to a system that produces wellness, not one that simply reacts to sickness. Without elevating this debate above the question of insurance coverage, costs will continue to escalate and the current unsustainable financial equation will not change.
If we are serious about dealing with the growing crisis in the U.S. health care system, we must foster an objective examination of the public subsidies and assumptions that underlie the current system as well as what we are buying and getting for the billions of dollars we invest in health care. And that is exactly what the Archimedes Movement is attempting to do.
The bold step taken by Massachusetts has refocused the nation on the glaring deficiencies of the current system – but we cannot go just half way. This must become a debate about health, not just health care. Massachusetts has opened the door – now we must find the courage to step across the threshold.
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